ATI Acute Respiratory Failure Test Bank,

Chapter 14: Chamberlain College of Nursing

NR 341 (A Graded) Latest Questions and

Complete Solutions

Chapter 14: Acute Respiratory Failure

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a patient with acute respiratory failure and

identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. A

nursingintervention relevant to this diagnosis is:

a. Elevate head of bed to 30 degrees.

b. Obtain order for venous

thromboembolism prophylaxis.

c. Provide adequate sedation.

d. Reposition patient every 2 hours.

ANS: D

Repositioning the patient will facilitate mobilization of secretions. Elevating the head

ofbed is an intervention to prevent infection. Venous thromboembolism prophylaxis is

ordered to prevent complications of immobility. Sedation is an intervention to

manage anxiety, and administration of sedatives increases the risk for retained

secretions.

DIF: Cognitive Level: Analysis REF: Nursing Care Plan

OBJ: Formulate a plan of care for the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

2. The patient with acute respiratory distress syndrome (ARDS)

wouldexhibit which of the following symptoms?

a. Decreasing PaO2

levels despite increased

 1 / 3

FiO2

administration

b. Elevated alveolar surfactant levels

c. Increased lung compliance with increased

FiO2

administration

d. Respiratory acidosis associated with

hyperventilation

ANS: A

Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels

areoften diminished in ARDS. Compliance decreases in ARDS. In early ARDS,

hyperventilation may occur along with respiratory alkalosis.

DIF: Cognitive Level: Comprehension REF: p.

410OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse assesses a patient who is admitted for an overdose of

sedatives.The nurse expects to find which acid-base alteration?

a. Hyperventilation and respiratory acidosis

 2 / 3

b. Hypoventilation and respiratory acidosis

c. Hypoventilation and respiratory alkalosis

d. Respiratory acidosis and normal oxygen

levels

ANS: B

Hypoventilation is common after overdose and results in impaired elimination of

carbondioxide and respiratory acidosis. The overdose depresses the respiratory drive,

which results in hypoventilation, not hyperventilation. Hypoxemia is expected

secondary to depressed respirations.

DIF: Cognitive Level: Analysis REF: p.

401OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. Intrapulmonary shunting refers to:

a. alveoli that are not perfused.

b. blood that is shunted from the left side of

the heart to the right and causes heart

failure.

c. blood that is shunted from the right side

of

the heart to the left without oxygenation.

d. shunting of blood supply to only one

lung.

ANS: C

Shunting refers to blood that is not oxygenated in the lungs.

DIF: Cognitive Level: Comprehension REF: p.

401OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. When fluid is present in the alveoli: